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SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU State Exam RSU January 2022 Surgery 1  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU 1. Actions for the prevention of infections in surgical wounds. Preopera...

SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU State Exam RSU January 2022 Surgery 1  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU 1. Actions for the prevention of infections in surgical wounds. Preoperative Shorten preop stay Antiseptic shower Hair clippers Postpone surgery or treat remote infection Patient: o Optimize nutrition o Pre – operative warming o Strict glucose control (80 – 100) o Smoking cessation Intraoperative Postoperative Sterile instruments and gown Early drain removal Antiseptic skin preparation Avoid postoperative bacteremia Control spillage Patient Patient: o Early enteral Nutrition o Supplemental O2 (80%) o Supplemental O2 o Intra operative warming o Strict glucose control o Fluid resuscitation o Surveillance programs o Strict glucose control 2. Types of blood product transfusion. Different types of packed red cells, indications to use them Types of blood product transfusion  Transfusion of autologous blood o preparation of recipient’s blood in time interval before more severe operations in case this is bearable for recipient’s general health as well as in all cases, when recipient is reluctant to receive blood or blood components of other donors  Reinfusion o of patient’s blood, which is collected from serous cavities after trauma and/or operation by using the special equipment for blood collection, washing and reinfusion o not if: infected blood with microorganisms, containing amniotic fluid, btained after liver trauma  Blood exchange transfusion o In neonatal Rh and ABO hemolytic disease, neonatal jaundice and in all cases of neonatal hemolytic disease induced by different antibodies of Rh and other systems (anti-c, anti-Kell) Types of Blood Products Whole blood transfusion – donor blood or recipient (autologous) blood  Rarely used except for massive transfusions for significant blood loss  Elective autologous blood transfusion for elective surgery Fractionated blood components  Packed RBCs  Indications:  Generally to maintain organ perfusion and tissue oxygenation  Acute hemorrhage and/or hypovolemic shock (e.g., gastrointestinal bleeding, trauma)  Symptomatic anemia (e.g., G6PD deficiency, aplastic anemia, Œ≤-thalassemia, sickle cell disease, anemia of chronic kidney disease)  Fresh frozen plasma - contains only plasma, all cellular components have been removed from the transfusion product  Warfarin overdose  DIC (clotting factor deficiency) 2  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU  substitution of plasma (in massive transfusion)  Platelet transfusion  Thrombocytopenia to prevent spontaneous bleeding  Massive blood loss  Cryoprecipitate  contains clotting factors (fibrinogen, factor VIII, factor XIII), vWF, and fibronectin  I: similar to FFP; preferable if large transfusion volumes are undesirable (Smaller volume than FFP)  Clotting factors  contains specific clotting factors that have been pooled frommultiple donors, e.g. prothrombin complex concentrate  specific clotting factor deficiencies  life-threatening bleeds  warfarin overdose  Antithrombin III  Indication: hereditary ATIII deficiency to optimize thrombosis prohylaxis with heparin, in DIC  Inhibition of coagulation: inhibition of thrombin, Xa, IXa, XIa, and XIIa Indication of RBC transfusion (General) Hospitalized patients (independent of clinical findings) with Hb ≤ 6 g/dL Hospitalized patients (hemodynamically stable) with < 7–8 g/dL  postoperative patients  ICU patients  cardiovascular disease  symptomatic anaemia 1 unit of packed RBCs increases Hb value approx. 1.0 g/dL 3. The most common acute and late response reactions to blood transfusion and possibilities to prevent them or decrease their incidence. Acute Response Reactions  refers to an immune or nonimmune-mediated adverse reaction that occurs during or within 24 hours of the transfusion of blood products Transfusion related acute lung injury (TRALI) o non cardiac pulmonary oedema due to plasma transudation into pulmonary interstitium Transfusion – associated circulatory (volume) overload (TACO) o prior to transfusion: increased susceptibility to volume overload due to heart failure, renal dysfunction, hypoalbuminemia, and/or positive fluid balance o Signs of hypervolemia: S3, Jugular venous distension. Peripheral edema and/or anasarca Bacterial contamination and endotoxemia Acute haemolytic reactions o Rapid onset during transfusion (because of preformed antibodies) or up to 24 hours after the transfusion o Clinical presentation ranges from asymptomatic to severe. o Symptoms include:  Fever, chills, nausea, flushing  Pruritus, urticaria  Flank pain or chest pain  Dyspnea, tachypnea  Burning pain at the IV site  Hypotension, tachycardia  Hemoglobinuria (due to intravascular hemolysis)  Jaundice (due to intravascular hemolysis)  Patients in a coma or under general anesthesia may present with oozing from wounds or puncture sites. 3  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU Nonhemolytic febrile reaction o rapid onset during or within 6 hours of transfusion (since cytokines are preformed) o Fever, chills, malaise, flushing, headache o More common in pediatric patients, Recurrence is rare Minor Allergic reactions o Onset during or up to 4 hours after transfusion o Pruritus, urticaria Anaphylactic Transfusion reaction o Sudden onset during or up to 3 hours after the transfusion o Shock, hypotension, wheezing, respiratory distress o Skin reactions (e.g., pruritus, urticaria) Late Response Reactions  refers to an immune-mediated adverse reaction that occurs > 24 hours after the transfusion of blood products (can be weeks to months later) Delayed haemolytic transfusion reaction (DHTR) o Onset days or weeks after transfusion (due to the delay in the anamnestic response) o Most commonly asymptomatic o Mild fever, Jaundice, Anemia o Chest, abdomen, or back pain Posttransfusion Purpura o Occurs in patients who had previously been sensitized to platelet antigens through pregnancy or transfusion Transfusion-associated graft-versus-host disease o consequence of a donor's lymphocytes proliferating and causing an immune attack against the recipient's tissues and organs, fatal in > 90% Iron Overload Transfusion hemosiderosis is common when patients with hematologic disorders require chronic transfusion. Prevention ABO blood typing before transfusion Crossmatching of donor blood and recipients’ blood before every transfusion Close monitoring of patient during transfusion for adverse reactions Observation of the patient during the initial 15 minutes of transfusion Prevention of anaphylactic transfusion reactions o Avoid plasma transfusions with IgA in patients known to be IgA deficient o Individuals with IgA deficiency should receive IgA-depleted blood products.  Febrile non haemolytic transfusion reaction  use of leukoreduced blood products TRALI o associated with donor products that contain large amounts of plasma from multiparous women recommended to use male-predominant plasma for transfusions Volume Overload – transfusion of lower volumes or at a slower rate Transfusion-associated graft-versus-host disease – gamma irradiation of blood products keeps the donor lymphocytes from proliferating 4  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU 4. Bleeding control types and methods. The body response to the blood loss. 1. Mechanical Methods Vessel Ligature (tie) o Ligation within the wound o Ligature in distance proximally Vessel tie together with surrounding tissue Vessel clip Used during the operation o Sterile Wax for Bone spongious part o Blacmore Tube 2. Physical Methods Electrocautery (bipolar / monopolar) Ultrasound (harmonic) Argon Beam (plasma) coagulator 3. Chemical Methods o Agents for topical (local) application  AgNO3 solution  H2O2 solution  KMnO4 solution  Epinephrine o Systemic action o Sol. Calcii chloridi 10% o Pituitrin (uteral contraction) o Protamine (protamin sulfate) o Aminocapronic acid Tranexemic acid o Aprotinine o Desmopressin 4. Biological methods o Agents for topical (local) application  Thrombin  Oxidated Cellulosis - SURGICELL®  TACHOSIL® , Fibrin Glue - TISSEEL®, Biological Glue - BIOGLUE® o Agents for general (parenteral) Administration o Vit. K – Phytomenadion (Konakion) o Prothrombin Complex (PCC) o Recombinant Factor VII A (NovoSeven®RT) o Octaplas o Cryoprecipitate (Fibrinogen) o Platelets , FFP 5. Combined methods: Diagnostic  selective angiography , Treatment  Therapeutic embolization Body response to blood loss  Respiratory system – increased rate and depth of respirations  Hematologic system o Coagulation cascade is activated  contraction of bleeding vessels by thromboxane A2 release o Platelets are activated and form an immature clot on the bleeding source o Damaged vessel exposes collage that causes fibrin deposition 5  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU  Cardiovascular system o Acute blood loss causes a fall in central venous pressure and cardiac filling leads to reduced cardiac output and arterial pressure o Fall in BP activates sympathetic adrenergic system  stimulates heart (increase heart rate and contractility) and constricts blood vessels (increase systemic vascular resistance)  Renal system o Increased release of renin  increased circulating levels of angiotensin II and aldosterone  causes vascular constriction, enhanced sympathetic activity, stimulation of vasopressin release o activation of thirst mechanisms o increased renal reabsorption of sodium and water to increase blood volume  Neuroendocrine system o ADH release from posterior pituitary gland in response to decrease of BP and o decrease in sodium concentration  leads to increased reabsorption of water and sodium 5. Factors for wound complications and their development Systemic factors ääLocal  inadequate perfusion  Ischemia  inflammation  Local infection  metabolic disease  Foreign body  Liver disease  Oedema (increased tissue pressure)  Immunosuppression  CT disorders  Poor nutrition (deficits) Risk factors for delayed wound healing: DID NOT HEAL  Vitamin deficit  Drugs (e.g., steroids, cytotoxics, and other  Microelement deficit immunosuppressive agents)  Anemia  Infections/Ischemia  Uremia, Haemodialysis  Diabetes  Malignancy  Nutritional deficiency (e.g., iron-deficiency  Diabetes anemia)  Smoking  Oxygen (hypoxia)  Age  Toxins (e.g., alcohol consumption, smoking)  Hypothermia/hyperthermia  Excessive tension on the wound edges  Acidosis/Another wound  Local anesthetics 6. The most common complications and their prevention strategy in early post-operative period. Direct post-operative period – 24h (72h are the most crucial) Early post-operative period – first 7 days Post-operative complications o Wound-related complications  Postoperative hemorrhage  Wound hematomas or seromas  Surgical site infection  Wound dehiscence – spontaneous wound rupture along a surgical incision with fascial dehiscence and possible prolapse of underlying structures/organs  Incisional hernia (late) General postoperative o Postoperative fever o Postoperative delirium o Postoperative nausea and vomiting o Postoperative ileus 6  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU o Deep vein thrombosis o Pressure ulcers Postoperative cardiac o Myocardial infarction o Arrhythmias (esp. atrial fibrillation) Postoperative pulmonary complications o Postoperative atelectasis o Pneumonia (aspiration) o Pulmonary embolism Renal and urinary tract complications o acute kidney injury (acute tubular necrosis following uncorrected hypotension) o Postoperative urinary retention o Catheter-associated urinary tract infection Prevention Assess risk of patient before surgery, optimizing medication Monitoring of vital signs Pain treatment, PONV prophylaxis with ondansetron (post operative nausea /vomiting) Adequate hydration and nutrition Early mobilization Antithrombosis prophylaxis – compressive stockings, sc LMWH Catheterisation – if voiding not possible or prolonged immobilization Breathing exercises Regular wound dressing and drainage control Stress ulcer prophylaxis with PPIs 7. Erysipelas: aetiology, clinical picture, treatment principles.  superficial skin infection involving the upper dermis Aetiology  Beta-hemolytic streptococci: mostly group A Streptococcus (S. pyogenes)  S. aureus  Entry is commonly via a minor skin injury ; erysipelas can consequently spread via superficiallymphatic vessels. Clinical Picture  Local signs: erythema, edema, warmth, tenderness o Specific to erysipelas: raised, sharply demarcated lesion  Cutaneous lymphatic edema (historically referred to as “peau d'orange”)  Common locations: lower limbs, face  Possible additional features o Lymphangitis: red streaks radiating from the skin lesion and following the direction of the lymphatic vessels o Lymphadenitis: swollen, tender, regional lymph nodes o Bullae o Purulent exudate  Systemic symptoms (in moderate/severe infections): fever, chills, confusion, nausea, headache, muscle and joint pain 7  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU Treatment Principles  Supportive care o Elevation of affected limb o Rest and pain management  Mild disease: o oral penicillin if culture is positive of S. pyogenes o or dicloxacillin / clindamycin  Moderate: Ceftriaxone, cefazolin, clindamycin orally  Severe disease or systemic features: o i/v vancomycin + Pip/Taz o Preventive antibiotic therapy to avoid recidive o C&S C&S  Culture and Sensitivity I&D  Incision and Drainage 8. Skin, subcutaneous and bone panaritium: clinical features, treatment. Skin panaritium  Clinical features o Pulsating pain, redness, swelling, warmth o Epidermal elevation caused by edema, pus collection o Often becomes a subcutaneous infection  Treatment o Alcohol application and immobilization o Antibiotics (e.g. amoxicillin-clavulanate) if infection is extensive o Surgical drainage if abscess is present Subcutaneous panaritium  Clinical features o Pulsating pain, redness, swelling, warmth o Lymphangitis, lymphadenitis o General symptoms – fever, chills increased inflammatory parameters, sepsis  Treatment o Immobilization, bathing in antiseptic solutions, physical procedures, therapeutic physiotherapy o Antibiotics o Surgical incision and drainage Bone panaritium  Clinical features o Localized, pulsating pain; redness, swelling, warmth, limited movement Lymphangitis, lymphadenitis o General symptoms – fever, chills, increased inflammatory parameters, sepsis Usually a complication of a cutaneous or subcutaneous panaritium  Treatment o Immobilization o Antibiotics – locally or intravenously, e.g. vancomycin o Abscess drainage, debridement of necrotic bone and tissue o Amputation of distal phalanx 8  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU 9. Indications and choice of operative approach for adrenal operations. Indication  Conn syndrome  Pheochromocytoma  Metastatic tumours  Adrenocortical carcinoma  Neuroblastoma (paediatric population) Choice of operative approach  Laparoscopic adrenalectomy o 90% of adrenalectomies are performed laparoscopically. o Advantages  reduced length of hospitalization  reduced pain  decreased operative blood loss  lower rate of postoperative complications, compared with conventional open surgery o Posterior retroperitoneoscopic approach  tumours < 7cm  Bilateral tumours  in patients with a history of extensive prior abdominal surgery  more challenging in older, obese male patients because of increased retroperitoneal fat, making initial entry and orientation more difficult o Lateral transabdominal technique  offers a wider operative field and greater versatility  suited for larger tumours  obese patients  Open adrenalectomy o Open anterior transabdominal approach, which is performed through a subcostal incision should be performed  primary adrenal tumours demonstrating features suggestive of malignancy, such as  large size (> 8 cm)  clinical feminization  hypersecretion of multiple steroid hormones  any of the following imaging attributes: o local or vascular invasion o regional adenopathy, and metastases. 10. Primary hyperparathyroidism (pHPT) - diagnostics, types of operations, intraoperative parathormone monitoring, perioperative management. Diagnosis  Laboratory tests o ↑ Serum calcium o ↑ PTH o Serum Phosphate: low  Hypophosphatemia o ↑ Alkaline phosphatase  Urine Test o 24 hour urine calcium and creatinine  Hypercalciuria in 24-hour urine collection  screen for increased risk of kidney stones and for Familial hypocalciuric hypercalcemia  Imaging o DEXA  measurement of bone mineral density at the lumbar spine, femoral neck, distal radius o Non contrasted CT o Ultrasound/nuclear imaging (Tc99m-sestamibi scan): only performed prior to surgery to determine the exact location of the abnormal glands 9  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU  Genetic testing o Patients with pHPT less than 40 years with multigland disease o patients with a family history of pHPT or syndromes associated with pHPT Types of operations 1. Parathyroidectomy o In cases of solitary adenoma o Only the respective gland is removed. 2. Total parathyroidectomy o In cases of hyperplasia, all 4 glands are removed o 50% of one of resected glands can be reimplanted in shallow pockets of sternocleidomastoid or brachioradialis muscle – a reimplanted gland allows for easier and faster surgical access if intervention due to pHPT relapse is indicated 3. Tumor resection o In cases of carcinoma o Includes removal of ipsilateral thyroid lobe and enlarged lymph nodes Possible procedures  open parathyroidectomy  endoscopic parathyroidectomy  minimally invasive parathyroidectomy (focused, video-assisted or radionucleotide-guided) Intraoperative PTH monitoring  guides the surgeon on when to stop the parathyroid exploration.  helps confirm that there is no residual hyperfunctioning parathyroid tissue  The PTH level is expected to drop after the pathologic gland(s) are excised due to the short half-life of PTH (3–5 minutes)  PTH levels are drawn at the following time points: 1. pre - incision (at a date prior to surgery or prior to starting the operation on the day of surgery) 2. pre - excision (after exposing an abnormal gland but prior to ligating the blood supply to the gland) 3. 5 minutes after gland removal 4. 10 minutes after gland removal  a more than 50% decline in PTH at 10 minutes following parathyroid gland removal compared to the highest baseline level, either the pre - incision or pre - excision, suggests cure and the procedure can be terminated (based on MIAMI criteria) Perioperative Management  Patient education and consent  Blood analysis – CBC and routine chemistry, electrolytes (esp. calcium), PTH, Vit D, urine calcium  Discontinue anticoagulation before surgery  Preoperative parathyroid localization studies – ultrasound/nuclear imaging, CT or MRI  Intraoperative neuromonitoring (Recurrent laryngeal nerve monitoring)  Complications of surgery o Swallowing difficulties or hoarseness – unilateral recurrent laryngeal nerve injury o Stridor – bilateral nerve injury o Horner syndrome – damage to the cervical sympathetic chain  Serum calcium should be checked within 6 - 8 hours after surgery and subsequently if abnormal  Symptomatic postoperative hypoparathyroidism – calcium, magnesium, and vitamin D derivative supplementation 10  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU 11. Thyroid cancer – diagnostics, principles of surgery and adjuvant therapy. Types  85% of thyroid cancers are papillary (from follicular cells)  20 – 30% follicular (from follicular cells)  3-5 % medullary (from parafollicular cells)  1,000 mg/dl) o Hypercalcemia o Post-ERCP o Drug-induced pancreatitis  Steroids  Azathioprine  Sulfonamides  Loop and thiazide diuretics  Estrogen  Protease inhibitors  NRTIs  Anticonvulsants o Scorpion stings o Viral infections (e.g., coxsackievirus B, mumps) o Trauma (especially in children) o Autoimmune and rheumatological disorders (e.g., Sjögren syndrome) o Pancreas divisum o Hereditary (e.g., mutation of PRSS1 gene, cystic fibrosis) Methods to detect severity 1. Ranson Criteria (≥3 defines severe pancreatitis) 2. APACHE II score o > 8 = severe pancreatitis o Can be used at admission and repeated at any time  BUT not specific for AP 3. Revised Atlanta Criteria 4. CRP >150mg/ml (severe) 5. Computed Tomography Severity Index (CTSI) 13  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU Disease Stages  Mild acute pancreatitis: interstitial edema, no necrosis; no local and systemic complications, no organ failure  Moderate acute pancreatitis: associated with local (e.g., necrosis, abscesses, pseudocysts) or systemic complications, such as temporary organ failure (e.g., kidney failure), which improves within 48 hours  Severe pancreatitis: associated with persistent pancreatic failure (> 48 hours), as well as single or multiple organ failure Atlanta criteria for acute pancreatitis. Organ Failure, as Defined by  Shock (systolic blood pressure 500 mL/24 hour) Systemic Complications  Disseminated intravascular coagulation (platelet count ≤100,000)  Fibrinogen 80 μg/dL  Metabolic disturbance (calcium level ≤7.5 mg/dL) Local Complications: Necrosis, Abscess, Pseudocyst 14. Diagnostics of acute necrotic pancreatitis. Diagnosis  Symptoms o prolonged fever, elevated white blood cell count o progressive clinical deterioration o Susception if: sepsis, SIRS, organ failure (>7 days after the onset of the AP) o Constant, severe epigastric pain (classically radiating towards the back) o Nausea, vomiting  Lab o ↑ Serum pancreatic enzymes  Lipase: if ≥ 3 x the upper reference range → highly indicative of acute pancreatitis  Amylase (nonspecific) o CBC - specific for necrotic pancreatitis  CRP > 120, increased LDH and haematocrit, hypocalcemia, increased creatinine  Elevated WBC, left shift  Imaging o Contrast enhanced CT  Lack of pancreatic parenchymal enhancement by i/v contrast agent and /or  Presence of finding of peripancreatic necrosis  air within the pancreatic necrosis seen on a CT scan confirms the diagnosis but is a rare finding o US for pancreatitis – can show evidence of necrosis o CT - guided percutaneous drainage + FNA o Culture of the aspirate + Gram Stain 14  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU 15. Main treatment principles of acute pancreatitis.  General measures o Admission to hospital and assessment of disease severity (consider ICU admission) o Fluid resuscitation: aggressive hydration with crystalloids (e.g., lactated Ringer's solution , normal saline) o Analgesia: IV opioids (e.g., fentanyl) o Bowel rest (NPO)and IV fluids are recommended until the pain subsides o Nasogastric tube insertion: not routinely recommended; indicated in patients with vomiting and/or significant abdominal distention o Nutrition  Begin enteral feeding (oral/nasogastric/nasojejunal) as soon as the pain subsides  Total parenteral nutrition: only in patients who cannot tolerate enteral feeds (e.g., those with persistent ileus and abdominal pain)  Drug therapy o Analgesics: fentanyl or hydromorphone; consider pump administration (patient controlled analgesia = PCA) o Antibiotics  Prophylactic antibiotic therapy is not recommended.  Antibiotics should only be used in patients with evidence of infected necrosis  Carbapenems: because of their penetration into the pancreas and spectrum coverage  Alternative therapy: Quinolones, metronidazole, third-generation cephalosporins, and piperacillin. o Fenofibrates: in hyperlipidemia-induced acute pancreatitis  Procedures/surgery o Biliary pancreatitis  Urgent ERCP and sphincterotomy (within 24 hours): in patients with evidence of choledocholithiasis and/or cholangitis; followed by cholecystectomy  Cholecystectomy (preferably during same admission once the patient is stabilized; or within 6 weeks): in all patients with biliary pancreatitis  The most important therapeutic measure is adequate fluid replacement (minimum of 3–4 liters of crystalloids per day)! "PANCREAS"  Perfusion (fluid replacement)  Analgesia, Nutrition, Clinical (observation)  Radiology (imaging)  ERC (endoscopic stone extraction)  Antibiotics  Surgery (surgical intervention, if necessary). 16. Mastitis – characterization of the clinical forms, symptoms. Principles of treatment, prevention. (Sabiston) 1. Lactational Mastitis  Breast feeding mastitis without abscess  Arise from entry of bacteria through the nipple into the duct system  Aetiology: Staph. Aureus  Symptoms o Fever, Leucocytosis o Erythema (usually unilateral) o Tenderness o parenchymal inflammation / swelling / firmness o breast pain, malaise, myalgia  Treatment o Frequent emptying of breast every 2 – 3 hours and alternating o Cold compress o Analgesics (ibuprofen) o Antibiotics 15  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU  Oral penicillinase-resistant penicillin or cephalosporin (e.g., dicloxacillin or cephalexin)  MRSA: clindamycin or vancomycin for severe cases o True abscess  FNA (under US guidance) + drainage + rinsing of cavity + Antibiotic (compatible with breast feeding)  Prevention o Anticipatory lactational counseling o To prevent recurrence: oral Lactobacillus probiotic 2. Chronic subareolar infections (non-lactational)  Chronic relapsing form  Develop in subareolar ducts (periductal mastitis)  Aetiology: o associated with smoking and diabetes o mixed bacteria (aerobic, anaerobic skin flora)  Symptoms o Series of infections with resulting inflammatory changes and scarring can lead to  retraction or inversion of nipple  masses in subareolar area  occasionally a chronic fistula from the subareolar ducts to the periareolar skin o subareolar pain o mild erythema  Treatment o Warm soaks o Oral antibiotics (Clarithromycin + Metronidazole or Amoxicillin / Clavulanic acid for 10 – 14 days) o Abscess:  FNA + antibiotics  Surgical incision and drainage o Repeated infections  Excision of entire subareolar duct complex after the acute infection has resolved completely + i/v antibiotic coverage o If erythema or edema persists, a diagnosis of inflammatory carcinoma should be considered and biopsy of the skin as well as underlying breast tissue will be needed 17. Breast cancer: clinical features, diagnostics, surgical treatment Clinical features  Most commonly, individuals with breast cancer develop clinical symptoms in later stages of disease.  Early stages o In early stages, affected individuals may notice a palpable mass with the following characteristics:  Typically single, nontender, and firm  Poorly defined margins  Most commonly located in the upper outer quadrant (∼ 55%)  Locally advanced disease o Locally advanced disease is characterized by a number of changes affecting the appearance of the breast. o Morphology: changes in size and/or shape → asymmetric breasts o Skin  Retractions or dimpling (due to fixation to the pectoral muscles, deep fascia, Cooper ligaments, and/or overlying skin)  Peau d'orange o Nipple  Inversion, Blood-tinged discharge 16  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU  Progressive disease o Ulcerations o Oedema of the arm o Paget disease of the nipple  Signs of metastatic disease o Lymphatic spread o Lymphadenopathy o Nontender, firm, enlarged lymph nodes (> 1 cm in size), that are fixed to the skin or surrounding tissue o Most commonly the axillary nodes and, in later stages, the supraclavicular and/or infraclavicular nodes Diagnosis  Clinical assessment of risk factors (increase endogenous/exog. Oestrogen, female, >65, smoking, alcohol)  Physical examination – bilateral breast inspection and palpation; palpation of axillar, supra- and infraclavicular LN  Radiographic imaging o Mammography o Breast ultrasound  Core needle biopsy (breast & LN) o to confirm diagnosis o indicated for a suspicious breast mass on ultrasound or mammography  Receptor testing of biopsy samples o Immunohistochemical staining for estrogen and progesterone receptor status (positive in 70% of cases) o FISH or immunohistochemical staining for HER2/neu positive (overexpression) in approx. 20% of cases o Triple-negative breast cancer  Oestrogen-negative  Progesterone-negative  HER2-negative  Approx. 10% of cases, typically more aggressive, high-grade tumors  Tumor markers – CA 15-3, CA 27-29, CEA  Detection of metastasis – MRI of brain and CT of chest, abdomen, and pelvis  TNM Grading Surgical treatment  Breast - conserving therapy (BCT) o Lumpectomy or quadrantectomy followed by radiation therapy  Mastectomy o Indications  if large tumor-to-breast ratio  multifocal tumors  fixation to chest wall  excision with negative tumor margins (> 2 mm) not guaranteed  involvement of skin or nipple o Types  Radical  removal breast, mm. pectorales (major/minor) + axillary lymph nodes  Total  removal of breast, nipple – areolar complex but not Mm. pectorales  Skin sparing  Nipple sparing  Intraoperative LN evaluation o Axillary dissection o Sentinel node biopsy o Marked node biopsy  Reconstructive surgery of breast 17  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU 18. Peritoneal adhesions: clinical features, diagnostics, surgical treatment.  bonds may be a thin film of connective tissue, a thick fibrous bridge containing blood vessels and nerve tissue, or a direct contact between two organ surfaces. Clinical Features  Often asymptomatic  Chronic (persistent or intermittent) bloating, abdominal cramping  Chronic abdominal pain  Altered bowel habits – constipation or frequent loose stools (e.g. from development of SIBO)  Nausea with or without early satiety  Bowel obstruction – may be transient, partial, or complete  Female infertility and dyspareunia Diagnostics  Predominately: intraoperatively  Anamnesis and history o open abdominal-pelvic surgery o inflammatory disorders o radiation therapy  Physical examination o increased bowel sounds, tympanism with percussion (when adhesions are obstructive), tenderness  Imaging o usually non-diagnostic, unless in acute obstruction o high-resolution ultrasonography o functional MRI  both detect limited movement relative to one another of organs joined by adhesions Surgical treatment  Asymptomatic adhesions do not require treatment o Adhesions which are only found incidentally or do not cause symptoms  do not dissect, because of risk getting more adhesions  Laparoscopic adhesiolysis  Laparotomy with open adhesiolysis  treatment of choice for acute complete bowel obstruction  How to dissect o Electrocautery o With little scissors o Cut in the middle or as far from intestine as possible  risk for perforation too high due to electro trauma 19. Radical and palliative surgical treatment methods of pancreatic tumours. Types of pancreatic tumours. Types of pancreatic tumours  Pancreatic exocrine tumours (95%) o Mostly ductal adenocarcinoma o Less common  Acinar adenocarcinoma (acinar cells produce digestive enzymes)  Signet cell carcinoma  Cystadenocarcinoma  Pancreatic endocrine tumours (neuroendocrine tumors/NET, < 5% of tumors) o Insulinomas (result in hypoglycemia) o Gastrinoma o Vasoactive intestinal peptide-producing tumours (VIPomas) o Pancreatic polypeptide-secreting endocrine tumours of pancreas o Glucagonomas, somatostatinoma 18  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU Radical surgical treatment options  Only curative treatment option – surgical resection, patients with operable tumors (∼ 20%) are always recommended for surgery  If surgical tumor resection is not possible or distant metastasis is present, a palliative approach is chosen  Pancreatic head carcinoma – pancreaticoduodenectomy ("Whipple procedure") o Resection of pancreatic head, distal stomach, duodenum, gallbladder, and common bile duct o Lymphadenectomy o Reconstruction by enteroenterostomy or Roux-en-Y anastomosis o Pylorus-preserving pancreaticoduodenectomy (Traverso-Longmire procedure)  Pancreatic body and tail carcinoma o Resection of the left side of pancreas with splenectomy o In some cases, duodenopancreatectomy with splenectomy – indicated in a curative treatment approach if partial removal of pancreas is insufficient  Neoadjuvant or adjuvant chemoradiotherapy o To reduce tumor size, improve symptoms, and prolong life o Chemotherapy or radiation therapy without surgery cannot cure the patient Palliative approach  Palliative chemotherapy – indicated in patients with advanced or metastatic pancreatic cancer  Analgesia according to the WHO step-by-step plan  Cholestasis  ERCP with stent implantation or percutaneous transhepatic bile duct drainage (PTCD)  Gastric outlet stenosis o Gastroenterostomy  stomach is anastomosed with the small intestine bypassing the duodenum  Percutaneous endoscopic gastrostomy (PEG) tube – indicated for severe palliative patients with chronic ileus and subileus that are inoperable  Cachexia o Nutrition counseling o Easily digestible foods (carbohydrates, little dietary fiber) o Small, frequent meals o Pancreatic enzyme supplements 20. Acute disorders of mesenteric blood circulation: aetiology (classification) and clinical features. Aetiology  Acute mesenteric arterial embolism (AMAE) o ∼ 50% of cases o Most commonly involves superior mesenteric artery (SMA) o generally resulting from atrial fibrillation, myocardial infarction, valvular heart disease, or endocarditis  Acute mesenteric arterial thrombosis (AMAT) o ∼ 25% of cases o due to pre-existing visceral atherosclerosis, arteritis, aortic aneurysm, or dissection  Nonocclusive mesenteric ischemia (NOMI) o ∼ 20% of cases o Typically seen in critically ill people with low cardiac output e.g. due to hypotension, vasopressive drugs, digitalis, ergotamines, cocaine  Mesenteric venous thrombosis (MVT) o < 10% of cases o predisposing factors include infection, malignancies, estrogen therapy, and hypercoagulability disorders 19  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU Clinical features  Periumbilical pain that is disproportionate to physical findings  Nausea and vomiting  Diarrhoea (bloody in later stages)  Gangrenous bowel – rectal bleeding and signs of sepsis (e.g. tachycardia, hypotension) Clinical courses  Acute arterial embolism o most abrupt and painful onset of all types (“abdominal apoplexy”) o severe abdominal pain, fever, bloody diarrhea o leukocytosis and atrial fibrillation  Acute arterial thrombosis – presentation less severe because patients have better collateral supply  Nonocclusive ischemia – symptoms develop over several days  Venous thrombosis – symptoms less dramatic, worsen gradually (abdominal discomfort evolves over a week) 21. Definition of polytrauma. Goals of primary and secondary survey. Definition  Polytrauma is defined as 2 or > injuries to physical regions or organ systems, one of which may be life threatening  A syndrome of multiple injuries of defined severity (Injury severity index (ISS) >16) with consecutive systemic reactions, which may lead to dysfunction of remote organs Primary Survey  Systematic evaluation  Detection and management of immediately life-threatening complications resulting from severe trauma.  Each step should be followed in the correct sequence, progress to the subsequent step only occurs if the prior step has been fully assessed/ managed o A – Airway (total spine control) o B – Breathing o C – Circulation (haemorrhage control) o D – Disability – brief neurological evaluation (AVPU) o E – Exposure – completely undress the patient  Great Mistakes of the Primary survey o Forgetting to look into mouth o Neglecting the spine o Inadequate examination o Leaving clothes on! o Resuscitation but not stopping the bleeding o Doing “D” before “C” o Under and over exposure Secondary Survey  Goal: to minimize risk of missed injuries by detailed physical examination (head – to toe) and history taking  Follow MIST o M – Mechanism of injury o I – Injuries suspected o S – Signs / Symptoms o T – Treatment  Injury Severity Score (ISS)   Modern Assessment of Blunt abdominal trauma by: o ISS scoring and o Emergency abdominal CT 20  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU 22. Goals and principles of Damage control surgery. Damage Control Surgery  Performed on selected critically injured patients rather than restoring anatomic integrity.  Goal: o to gain time to stabilize the severely traumatized patient o Optimize physiologic state before the definitive repair, based on the patient’s physiologic tolerance.  integrated approach: resuscitation and surgery are undertaken simultaneously in close communication of surgeon and anaesthesiologist  approach would provide a limited surgical intervention in order to control both haemorrhage and contamination 1. Stage – save the patient  > 24h 2. Stage – stabilization of vital functions  24 – 72h 3. Stage – definitive care > 72h  Stop the bleeding  Stop the contamination  Minimal stabilisation of fractures  Indications for DCS o High energy trauma o Multiple penetrating wounds (stabbed/gunshot) o Haemodynamically unstable patient  Critical factors (lethal triad) o Severe metabolic acidosis (pH < 7.30) o Hypothermia T° 10 Units of RBC)  After haemostasis and DCS  Temporary abdominal closure – VAAC (IAP-, ACS) 23. Diagnostic and treatment principles of liver trauma. Indications for operation/conservative treatment. Diagnostic Principles  Imaging to assess the location and extent of abdominal injury o FAST exam: to detect hemoperitoneum (collection of blood in the peritoneal cavity) o CT  If FAST is inconclusive and patient is stabilized  Detects free abdominal fluid  Solid organ injury  Retroperitoneal injury (e.g., upper retroperitoneal hematomas) o X-ray: less useful than CT or FAST  Detects fracture  Free intra-abdominal air  Large collections of blood  Diagnostic peritoneal lavage o Has been largely replaced by the rapid, noninvasive FAST exam o Useful for assessing hemodynamically unstable patients if FAST is inconclusive  Emergency laparotomy is indicated, if fecal matter or significant amounts of blood are detected (positive test)  Highly sensitive, but invasive  Negative FAST/CT: identify extra-abdominal cause of hemodynamic instability  Laparotomy is indicated for patients with o Hemodynamic instability o Signs of peritonitis o Intra-abdominal bleeding detected on imaging 21  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU  Grading of liver injuries I. Subcapsular hematoma < 10 % of surface area, laceration < 1 cm deep II. Subcapsular hematoma 10-50 %of surface area, laceration1-3cm deep; < 10 cm in length III. Subcapsular hematoma > 50 %of surface area or expanding, laceration > 3 cm deep IV. Parenchymal disruption involving 25-75 %of hepatic lobe or 1-3 Couinaud's segments in a single lobe V. Parenchymal disruption > 75 % of lobe or > 3 Couinaud's segments, juxtahepatic venous injuries (retro hepatic vena cava/hepatic veins) Principles of Treatment  Depended on Liver injury stages and hemodynamical status of the patient  Conservative approach o in haemodynamically stable patients o Grade I - III treated conservatively  Close monitoring of vital signs and serial examination  Angiography and embolization (control bleed) o 20 - 30% of grade IV and V injuries are being treated conservatively o Indications  Hemodynamic stability on admission or after initial resuscitation  Clear CT scan delineation of the liver injury and degree of free intra-peritoneal blood  No CT scanning evidence of associated enteric or retroperitoneal injuries  Liver-related transfusion limited to 4 units  CT-documented improvement or stabilization of the liver injury, when indicated Indications for Operation (from class notes and lectures)  Absolute indications for surgery o Persistent HD instability o 4 units of RBC due to liver trauma o Cannot control with angiography o Source of bleeding cannot be identified o Concomitant abdominal injuries  Relative indications for surgery o Surgeon is not experiences in conservative management o Interventional radiologist is not available o Insufficient blood bank resources o No endoscopist to treat late complications 24. Diagnostic and treatment principles of spleen trauma. Indications for operation/conservative treatment Diagnostics Laboratory tests – low Hb (in later stages), leucocytosis, and thrombocytosis; crossmatch for blood transfusion if needed In hemodynamically unstable patients o First ultrasound (FAST) – screening for central or subcapsular hematoma o If free intraabdominal fluid → diagnostic laparoscopy/laparotomy  In hemodynamically stable patients (or in unstable patients in which temporary stabilization with IV fluid resuscitation is successful) o Method of choice – abdominal CT scan (with contrast) o Alternative – MRI, angiography o Always consider other organs that could be injured 22  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU Treatment  Indications for conservative treatment o Low-grade injury in hemodynamically stable patients o Procedure  Repeated ultrasound examination (for approx. 10days)  Angiographic embolization of the injured blood vessel can be performed  Sport only after 3 months  Indications for surgery o High-grade splenic injuries and/or hemodynamically unstable patients o Procedure o Laparotomy  If only peripheral rupture – trial of splenic salvage – suturing, coagulation, or ligation of injured blood vessel  Alternative – partial splenic resection  If hilar rupture: splenectomy, if necessary with reimplantation of splenic tissue 25. Blunt trauma of pancreas – classification and treatment options  3-12% of all abdominal trauma  Types o Penetrating trauma 2/3 o Blunt trauma 1/3  In 75% of penetrating - v.cava and aorta is injuried  90% pancreatic injuries have associated injury  Early mortality is generally to exsanguinations!!!  Late mortality - fistula, pseudocyst, pancreatitis, anastomotic breakdown, intra-abdominal abscess 23  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU Classification Treatment  Mostly conservative therapy  percutaneous drainage (with culture) and debridement to prevent complications (pseudocysts, abscess)  Grade I – conservative  Surgery o Grade II – cons./distal resection/drainage o Grade III – drainage or distal resection o Grade IV – individualized approach (PDR, resection, etc.) o Inspection for central haematomas, peripancreatic oedema, retroperitoneal bile o Complete exposure of the gland is not necessary when there are no signs of bleeding and retroperitoneal duodenal injury 26. Primary, secondary, and tertiary peritonitis – definition and principles of treatment Peritonitis: inflammation of the peritoneum and peritoneal cavity usually caused by a localized or generalized infection  Primary o infection of the ascitic fluid in the absence of any focal intraabdominal, surgically treatable source of infection o Primary peritonitis (spontaneous bacterial peritonitis, or SBP) o Rare condition o results from bacterial, chlamydial, fungal, or mycobacterial infection in the absence of perforation or inflammation of the GI or GU tract. o 1% generalized peritoneal bacterial infection without loss of peritoneal barrier function (Cirrhosis, peritoneal dialysis, Neu >250/uL)  Secondary o Most common form, 80 - 90% o Loss of peritoneal barrier function o occurs in the setting of GI or GU perforation or inflammation with common causes including acute appendicitis, colonic diverticulitis, and pelvic inflammatory disease.  Tertiary: Persistence/recurrence after 48 hours of apparent resolution of primary and secondary peritonitis 24  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU Principles of Treatment  Antimicrobial therapy o Indications (presence of any of the following in a patient with cirrhosis and ascites):  Abdominal pain and/or tenderness  Fever > 37.8°C  Ascitic fluid neutrophil count ≥ 250/mm3 o Duration  Narrow antibiotic coverage according to bacterial susceptibility.  Continue antibiotic therapy for at least 5–7 days. o Broad spectrum A/B  First-line: 3rd-generation cephalosporin IV, preferably cefotaxime  Alternative: oral ofloxacin  Adjunctive therapy o IV albumin supplementation  Indications (any of the following):  Total bilirubin > 4 mg/dL  Blood urea nitrogen > 30 mg/dL  Creatinine > 1 mg/dL o Consider discontinuing beta blockers. o Discontinue diuretics. o Avoid potentially nephrotoxic medications (e.g., NSAIDs). o Consider discontinuing proton-pump inhibitors.  Supportive therapy o Electrolyte repletion o Analgesics as needed o Antipyretics as needed o IV fluids: Use caution in patients who are volume overloaded.  Monitoring and subsequent management o Serial abdominal examination o Repeat paracentesis: not routinely recommended  Worsening of signs and symptoms and/or lack of significant reduction in ascitic fluid neutrophil count (by at least 25%) after initiation of antibiotics indicates a potential failure of first-line antibiotic therapy and should raise suspicion of secondary bacterial peritonitis o Consider GI/hepatology consult or infectious disease consult. o Consider referral for a liver transplant evaluation 27. Complicated and uncomplicated intra-abdominal infection – definition and differences in the principles of management Intra-abdominal infection (IAI)  describes a diverse set of diseases.  broadly defined as peritoneal inflammation in response to microorganisms, resulting in purulence in the peritoneal cavity Classification  Uncomplicated abdominal infections o intramural inflammation of the gastrointestinal (GI) tract without anatomic disruption. o often simple to treat o can progress into complicated abdominal infection  Complicated abdominal infections o extend beyond the source organ into the peritoneal space o cause peritoneal inflammation, and are associated with localized or diffuse peritonitis 25  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU Differences in the principles of Management Empiric antimicrobial therapy  Timing o Complicated: receive empiric antimicrobial therapy as soon as possible, ideally once blood and urine samples have been obtained for culture. o Uncomplicated: delaying antibiotic therapy until samples from the site of abdominal infection have been obtained for culture can be helpful to optimize the microbiologic yield that guides subsequent antibiotic selection. Complicated 1. Rapid diagnosis 2. Identification of high risks patients 3. Fluid resuscitation 4. Empiric broad spectrum antimicrobial therapy a. Needs to be unaffected by ESBL to maintain successful surgery and treatment Community acquired  mild to moderate  Single-agent regimens – Ertapenem or piperacillin-tazobactam.  Combination regimens o Cefazolin, cefuroxime, ceftriaxone, cefotaxime, ciprofloxacin, or levofloxacin o each in combination with metronidazole (although for most uncomplicated biliary infections of mild to moderate severity, the addition of metronidazole is not necessary).  high risk  Single-agent regimens – Imipenem, meropenem, doripenem, or piperacillin-tazobactam.  Combination regimens – Cefepime or ceftazidime, each administered with metronidazole.  ESBL: Carbapenem (imipenem, meropenem, or doripenem) Health Care Associated  multidrug regimens that include agents with expanded spectra of activity against gram-negative aerobic and facultative bacilli o meropenem, imipenem cilastatin, doripenem, piperacillin-tazobactam, or ceftazidime or cefepime in combination with metronidazole. o Aminoglycosides or colistin may be required 5. Source control a. Percutaneous drainage b. Surgical intervention (close an anatomic breach or debride infected necrotic tissue) c. + collection of primary specimens for microbiologic analysis (Gram stain, aerobic and anaerobic cultures, and if appropriate, fungal and mycobacterial studies) 28. Classification of thoracic trauma, mechanisms of trauma. Principles of patient examination and diagnostic work-up. Classification By mechanism o Penetrating chest trauma e.g. gunshot wounds, stabbing o Blunt chest trauma – motor vehicle accidents (50–75%), falls, industrial or recreational accidents o Iatrogenic – thoracentesis, pleural puncture, tracheobronchial rupture by tracheotomy or intubation By location o Injury to ribcage – thorax contusion, rib fracture, sternum fracture, flail chest (more 3 ribs involved) o Injury to mediastinum – cardiac contusion, pericardial effusion, cardiac tamponade, aortic rupture, esophageal rupture, diaphragmatic rupture o Injury to lungs – pulmonary contusion, rupture of bronchus or trachea, pneumothorax, haemothorax Open vs closed o Closed chest trauma  without injury of intrathoracic organs  with injury of intrathoracic organs o Open trauma with injury of intrathoracic organs 26  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU Patient examination and diagnostics Physical examination o Primary survey – prehospital trauma care and preliminary trauma care in the hospital o Emergency assessment – of hemodynamically unstable patients to rule out life-threatening conditions  Trauma patient presenting with hypoxia and signs of shock requires immediate assessment for aortic injury, tension pneumothorax, cardiac tamponade, and hemothorax o Symptoms of organ injury – chest pain, hypotension, tachycardia, hypoxia, dyspnea  Pneumothorax – diminished breath sounds  Tracheal or esophageal injury – change in voice or foreign body sensation  Pericardial effusion – jugular venous distention Diagnostics o Chest x-ray – initial test for all blunt chest trauma patients o Ultrasound (extended FAST) o Echocardiography and ECG o Others – CT, transoesophageal echocardiography (TEE), bronchoscopy, angiography, endoscopy 29. Classification of pneumothorax. Spontaneous pneumothorax: clinical picture, diagnostics, treatment. Classification  Spontaneous pneumothorax o Primary (occurs in patients without clinically apparent underlying lung disease)  Young tall males, smoking  Radiology: Emphysema like changes, apical subpleural bullae o Secondary (COPD, Bullous disease, CF, Pneumocystis related , Congenital cysts, IPF, PE, Marfan, Catamenial (connected to endometriosis and menstrual cycle) o Neonatal  Acquired o Traumatic pneumothorax  Penetrating (stab wounds, gunshots)  Blunt (road accidents, fall from height, sport injuries)  Barotrauma o Iatrogenic pneumothorax  Mechanical lung ventilation  Needle puncture: thoracentesis, FNA lung nodule, central line insertion (subclavian vein), intercostal nerve block  Postsurgical o Tension pneumothorax  life-threatening variant of pneumothorax characterized by progressively increasing pressures within the chest and cardiorespiratory compromise  Pathologically – physiologically classification o Closed o Open o Tension Clinical Picture in Spontaneous pneumothorax  Patients range from being asymptomatic to having features of hemodynamic compromise.  Sudden, severe, and/or stabbing, ipsilateral pleuritic chest pain and dyspnea  Reduced or absent breath sounds, hyperresonant percussion, decreased fremitus on the ipsilateral side  Subcutaneous emphysema Diagnostics  Confirmation by chest x-ray – ipsilateral pleural line with reduced/absent lung markings, sudden change in radiolucency, ipsilateral hemi diaphragmatic elevation, deep sulcus sign 27  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU  Chest CT – may provide detailed information about underlying cause (e.g. bullae in spontaneous pneumothorax)  Arterial blood gas analysis (ABG) – to detect respiratory acidosis Treatment (Lecture)  Observation  Needle aspiration  Percutaneous catheter for drainage – Pleur-evac  Insertion of pleural drain – Under water seal, Heimlich valve  2nd pneumothorax or chronic: Insertion of pleural drain & chemical pleurodesis  Surgical approach o VATS o Thoracotomy Amboss  Simple pneumothorax o If small (≤ 2 to 3 cm between lung and chest wall on a chest x-ray) and asymptomatic o Usually resolve spontaneously within a few days (∼ 10 days) o Supplemental oxygen (4-6 L/min) via nasal cannula or mask with reservoir o Serial follow-up with repeat CXR (after 3 – 6 hours)  If small and symptomatic (but hemodynamically stable) or large (> 3 cm between lung and chest wall on chest x-ray) primary or secondary pneumothorax o Immediate supplemental oxygen (4-6 L/min) via nasal cannula or mask with reservoir o Upright positioning, symptomatic treatment o Tube thoracostomy – insertion of Bülau drain in 4th intercostal space (nipple line) in between anterior and median axillary line (safe triangle; midaxillary line) Main principles of surgical treatment (Lecture)  Diagnostics of reason for pneumothorax  Elimination of reason o Suturing or resection of apical blebs (using of fibrin glue) o Resection of big / giant bullae o Suturing of diaphragm (if defects)  Prophylaxis for relapsing pneumothorax o Pleural abrasion o Parietal pleurectomy (apical, total) o Chemical pleurodesis with talc (Caolin, bleomycin, tetracycline) Indications for Surgery (Lecture)  Prolonged air-leakage (>5days)  Air-leak, which doesn’t allow lung to expand  Relapse of Pntx (2nd episode)  1st episode of Pntx, if: o Pntx on another side in anamnesis o Patient has undergone pneumonectomy o Professional riskiness (pilots, divers,etc.)  Bilateral Pntx  Complications of Pntx: Haemothorax. Empyema, Chronic Pntx  Specific indications for secondary Pntx (big cysts, giant bulae, etc.) 30. Tension pneumothorax: clinical symptoms, diagnosis, treatment Clinical Symptoms  Sudden, severe, and/or stabbing, ipsilateral pleuritic chest pain and dyspnea  Reduced /absent breath sounds, hyper resonant percussion (tympanic sound) decreased fremitus on the ipsilateral side  Subcutaneous emphysema  Severe acute respiratory distress: cyanosis (late manifestation), restlessness, diaphoresis 28  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU  Reduced chest expansion on the ipsilateral side  Distended neck veins and hemodynamic instability (tachycardia, hypotension, pulsus paradoxus)  Secondary injuries may be present (e.g., open or closed wounds)  Mediastinal shift  Signs of tension pneumothorax in ventilated patients o Tachycardia, hypotension (obstructive shock) o Distention of jugular vein (due to increased high thoracic pressure) o Rapid decrease in SpO2 o Reduced air flow o Increased ventilation pressure o Skin emphysema Diagnosis  Primarily a clinical diagnosis – prolonged diagnostic studies should be avoided to initiate immediate treatment  Chest x-ray o ipsilateral pleural line with reduced/absent lung marking o sudden change in radiolucency o ipsilateral diaphragmatic flattening/inversion o widened intercostal spaces o tracheal deviation towards the contralateral side Treatment  Emergency chest decompression o Chest tube placement if immediately available  Most commonly in the 4th-5th intercostal space (nipple line), between the anterior and midaxillary line (safe triangle)  Rarely: second intercostal space, midclavicular line (Monaldi drain) o Emergency needle thoracostomy  Insertion of a large-bore needle into 2nd intercostal space along the midclavicular line  followed by chest tube placement o Finger Thoracostomy 31. Traumatic haemothorax. Aetiology, diagnostic work-up and treatment principles. Definition: collection of blood within the pleural space due to trauma Aetiology  Most commonly due to penetrating or blunt trauma o Single rib fracture can cause blood loss of 100ml Diagnostics  Physical examination o Chest wall deformity o Paradoxical chest wall movement o Crepitus on palpation o Diminished / absent breath sounds  Chest x-ray: similar appearance to pleural effusion o Opacity (Detection is usually possible if amount of fluid is > 200–300 mL) o Blunting of the costophrenic angle o Tracheal deviation (mediastinal shift)  Ultrasound: detection of smaller amounts of fluid/blood than on chest x-ray possible o A hyperechogenic signal is first seen in the costodiaphragmatic recess. o Commonly used in the FAST protocol for trauma assessment 29  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU Treatment  Chest tube insertion into the 5th intercostal space at the midaxillary line o upper rim of lower rib  to avoid damage to intercostal nerves o Connect it to under water seal o Big diameter (Ch 36): BUT must be decide individually for each patient o VATS: for exploration & evacuation of retained clotted haemothoraces  Thoracotomy indicated if o Antero – lateral o Chest tube output > 1500 mL immediately after placement or 200 mL/hour for 2–4 hours o Multiple transfusions required Additional Info: In rib fractures: o Aggressive pain management!!!  pat. does not want to move because of pain and starts hyperventilation  NSAIDS, weak opiates  multimodal approach (avoid opiates, when possible, maybe add TCA (WHO pain ladder)  Epidural, paravertebral, intercostal catheters o Operative fixation:  Strasbourg thoracic osteosynthesis systems (STRATOS)  Synthes rib fixation system (matrixRIB) 32. Oesophageal cancer: risk factors, clinical symptoms, diagnostic work-up (including preoperative diagnostic work-up). Risk factors  Adenocarcinoma (mostly in lower 1/3 of oesophagus) o Smoking, Obesity o Endogenous risk factors  Male sex, older age (50-60 years)  Gastroesophageal reflux  Barrett oesophagus  Squamous cell carcinoma (mostly in upper 2/3) o Exogenous risk factors  Alcohol consumption  Smoking (ninefold risk)  Diet low in fruits and o Endogenous risk factors vegetables  Male sex, Older age (60-70  Hot beverages years)  Nitrosamine’s exposure (e.g.,  African American descent cured meat, fish, bacon)  Plummer-Vinson syndrome  Caustic strictures  Achalasia  HPV  Diverticula (e.g., Zenker's  Radiotherapy diverticulum)  Oesophageal candidiasis Clinical Symptoms  Early stages o Often asymptomatic o May manifest with swallowing difficulties or retrosternal discomfort  Advanced stages o General signs: Weight loss, Dyspepsia, Signs of anemia o Signs of advanced disease  Progressive dysphagia (from solids to liquids) with possible odynophagia  Retrosternal chest or back pain  Cervical adenopathy  Hoarseness and/or persistent cough  Horner syndrome o Signs of upper gastrointestinal bleeding  Hematemesis, Melena 30  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU Diagnostic work up  Esophagogastroduodenoscopy o best initial and confirmatory test o Direct visualization of the tumour o Allows biopsy of any suspicious lesions  Barium swallow o indicated in severe stricture that inhibits endoscopic evaluation or suspected tracheoesophageal fistula due to oesophageal cancer  Staging (preoperative) o Transoesophageal endoscopic ultrasound – to determine infiltration depth and register regional lymph node disease o Chest and abdominal CT and/or PET – to identify location and content of lesion and to exclude distant mts o Bronchoscopy (staging of lesions at or above carina) o Laparoscopy (staging of lesions at esophagogastric junction)  Laboratory – nutritional status (albumin), liver function in alcoholic patients 33. Radical and palliative surgery for oesophageal cancer. Curative / Radical  Indication o Locally invasive disease that has not invaded surrounding structures o High-grade metaplasia in Barrett syndrome  Methods o Neoadjuvant chemoradiation: as definitive treatment in patients with proven complete response (e.g., during endoscopy) o Surgical resection  Endoscopic submucosal resection for removal of superficial, epithelial lesions  Subtotal or total esophagectomy with gastric pull-through procedure or colonic interposition Palliative  Indication: patients with advanced disease (majority of patients)  Methods o Chemoradiation o Stent placement o Other endoscopic treatments (e.g., laser therapy) 34. Oesophageal perforation: causes, clinical symptoms, diagnostic work-up, treatment. Causes  Iatrogenic esophageal perforation o Most common cause of esophageal perforation o Most often injury during upper endoscopy  Ingestion of a foreign body or caustic material  Trauma (blunt or penetrating)  Malignancy  Infection  Spontaneous rupture  Boerhaave Syndrome o Risk factors  Intake of large amounts of alcohol or food in the recent past  Repeated episodes of vomiting  Prolonged coughing  Childbirth  Seizures  Weightlifting 31  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU o Pathophysiology  Severe vomiting/increased intrathoracic pressure  rupture of all layers of the esophageal wall (transmural perforation)  In > 90% of cases, the rupture occurs in the distal third of the esophagus on the left dorsolateral wall surface. Clinical Symptoms  Mackler triad (esp. in Boerhaave syndrome) o Vomiting and/or retching o Severe retrosternal pain that often radiates to the back o Subcutaneous or mediastinal emphysema: crepitus in the suprasternal notch and neck region or crunching/crackling sound on chest auscultation (Hamman sign)  Dyspnea, tachypnea, tachycardia  Dysphagia  Signs of sepsis  History of recent endoscopy: Symptoms usually occur within 24 hours of endoscopy.  Delayed presentations: critically ill with sepsis and multiorgan dysfunction Diagnostic  Initial diagnostic study o Neck x-ray : subcutaneous emphysema o Chest x-ray  Widened mediastinum  Pneumomediastinum, pneumothorax, pneumoperitoneum, subcutaneous emphysema  Pleural effusion  Confirmatory test: Contrast leak on contrast esophagography (with gastrografin) (gold standard) reveals the location and size of the rupture.  CT scan o Indications  The patient is unstable/uncooperative.  Pneumoperitoneum is detected on x-ray.  X-rays and contrast esophagography are inconclusive. o Findings  Widened mediastinum  Esophageal wall thickening, hematoma  Extraluminal air: pneumomediastinum, pneumoperitoneum, pneumothorax, subcutaneous emphysema  Pleural effusion  Flexible endoscopy o Consider if the CT scan is inconclusive. o Should be reserved for patients with a poorly localized esophageal perforation and those with a therapeutic indication for endoscopy Treatment Initial approach  ABCDE survey  Establish airway and/or provide supplemental oxygen as needed Nonsurgical treatment  Indications o Small, contained perforation, demonstrated by:  Either a contained leak with the neck, within the mediastinum, or between the mediastinum and visceral lung pleura  IV fluid resuscitation  Nothing by mouth (NPO) and supply nutritional support  Broad-spectrum IV antibiotics (see empiric antibiotic treatment for intra-abdominal infection)  IV proton pump inhibitor (e.g., pantoprazole)  Parenteral analgesics (see acute pain management) 32  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU Surgical treatment  Indications o Hemodynamic instability o Patients who do not fulfill the criteria for conservative management o Clinical deterioration during conservative management  Surgical repair o Closure of the ruptured esophageal segment o Last resort: esophagectomy with gastric pull through or colonic interposition 35. Endoscopic treatment options for tumours of trachea, bronchi, and oesophagus  Used for acute obstruction or as adjuvant therapy  Endoscopic resection in oesophagus o Possible in tumor stages T1N0M0 – adenocarcinoma, squamous cell carcinoma or relapse o Complete resection – en-bloc resection by endoscopic mucosa resection or endoscopic submucosa resection  Bronchoscopic resection of tracheobronchial tumours o Can be performed for benign tracheobronchial tumors or minimally invasive endobronchial lesions o Endoluminal core-out of tumours – considered when temporizing or palliative restoration of airway lumen is required o Procedure can be repeated, but bronchoscopy is usually not employed for prolonged palliation o Techniques are thermal coagulation (electrocautery), argon plasma coagulation, laser and cryotherapy  Palliative care – stenting or balloon dilation of trachea, bronchus or oesophagus 36. Diaphragmatic relaxation: aetiology, diagnostic work up, treatment. Causes  Permanent elevation of hemidiaphragm due to muscle weakness  Might be inherited or acquired  N. phrenicus function loss o Iatrogenic due to cut in cardiac surgery  valve surgery o Infection  viral: HIV, West Nile virus, poliomyelitis virus  bacterial: Lyme disease o Non-infectious: Sarcoidosis, Amyloidosis o Autoimmune disorder Diagnostic work up  Symptoms: o Most patients with unilateral diaphragmatic weakness are asymptomatic and are detected incidentally. o 1/3 of patients report exertional breathlessness  Imaging o Chest X – ray:  diaphragm elevated (sometimes into thoracic cavity) mono or bilateral  An upward located diaphragm  cause second. atelectasis of the lower sub-segments of the lung o Fluoroscopic test:  All patients with suspected diaphragmatic weakness should undergo a fluoroscopic test to diagnose the functional weakness.  unilateral weakness: the diaphragmatic excursion will be reduced or absent  bilateral weakness: diaphragm either does not move or moves paradoxically, depending on the severity of weakness. o Ultrasound of thorax:  Normally: diaphragm appears as a thick echogenic line in B mode. 33  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU  In M mode, a paralyzed hemidiaphragm will show no cranial movements of paradoxical caudal movements, similar to a sniff test o CT chest: should done in all patients with diaphragm weakness to rule out any thoracic aetiology. o Pulmonary function tests:  FVC: will decline  by 50% predicted  unilateral diaphragmatic weakness  up to 75%  bilateral weakness  Total lung capacity, functional residual capacity, residual volume, and diffusion factor remain unchanged in unilateral weakness but can be reduced in bilateral weakness o Electrophysiological tests:  Diaphragmatic electromyography  phrenic nerve is stimulated electrically, and the mechanical response of the diaphragm is detected along with trans-diaphragmatic pressure  Phrenic nerve pathology  prolonged latency and reduced trans-diaphragmatic pressure Treatment  Idiopathic conditions: wait 6 months until surgery  if reason is viral infection  it resolves with antiviral therapy and no need for surgery Surgical approaches  Diaphragm Plication: o involves tying the affected side of the diaphragm to the side that is still functioning normally  prevents the weakened diaphragm from becoming elevated in the chest cavity and allows the lungs to expand more efficiently and making breathing easier o Open (thoracotomy) or VATS approach  Diaphragmatic Pacing: o If the phrenic nerve is intact o minimally invasive surgical option that involves placing a pacemaker to regulate breathing by electrically stimulating the phrenic nerve. 37. Lung abscess: clinical symptoms, diagnosis, treatment.  mainly as complication of aspiration pneumonia (anaerobes) Clinical Symptoms  Onset o Typically indolent; symptoms can evolve over weeks to months but may also be acute in onset. o Acute: symptoms for < 4–6 weeks o Chronic: symptoms for > 6 weeks o Pneumonitis  tissue necrosis after 7 – 14 days  abscess or empyema (closed period  open period)  Characteristic symptoms o Fever (high fever in closed and subfebrile in open period) o Cough with production of foul-smelling purulent and sour tasting sputum (in open period) o Night sweats o Pleuritic chest pain o Fatigue o Hemoptysis o Anorexia, weight loss  Pulmonary examination findings o Digital clubbing in chronic abscess o Dullness to percussion over the affected area o Amphoric breath sounds may be present over the lung abscess 34  SURGERY - S T ATE EXAM J ANU AR Y 2022 – RSU Diagnosis